Quote from: dominicus on August 09, 2013, 01:05:24 AM

Quote from: smscotten on August 08, 2013, 11:06:00 AM

the fundamental problem is that costs are too high. All the rest of what you're talking about stems from that simple fact.

No, I disagree. You're confusing problem with symptom. The high prices (and poor overall outcomes) of US healthcare relative to other countries is a *symptom* of the dysfunction in the current system. It is not, by itself the cause.

I'll agree that there are root causes for the high prices, but if the prices were not high, people wouldn't be going bankrupt. Bring prices down (whether it is by government decree or market mechanismsit doesn't matter for this part of the discussion) and people get affordable health care and don't go bankrupt any more and everyone is happy.

So the dysfunction in the system would be no big deal if it didn't drive costs and prices up, pricing people out of the healthcare market and forcing them to rely on insurance.

Quote from: dominicus on August 09, 2013, 01:05:24 AM

One of the big issues resulting in high individual pricing is that the healthcare revenue pool is currently not well-aligned with the cost pool. This causes a huge amount of unpaid costs and preventable emergency care costs to be tacked on to those who responsibly have insurance and pay their bills, including business-financed health plans. Again issue->misalignment, symptom->high prices to those that actually pay for healthcare. Alignment of revenue & costs is a key part of the solution. Freeriders be gone.

That's a real part of the problem, but last I looked at the numbers it was not the bulk of the problem. Maybe you have newer numbers?

Quote from: dominicus on August 09, 2013, 01:05:24 AM

The other big issue is citizen unwillingness/inability to afford healthcare planning en-masse. Why do people find themselves with crushing medical debt, unprepared, and even uninsured? There's a whole number of reasons this happens, and only a few are individually controllable.

Making more rational choices about insurance and out-of-pocket costs are a step in the right direction. Me doing it? Not so much. But if more people did, well, pharma companies charge $500 per pill because they know that the insurance companies will pay it no matter what, and because they can manipulate doctors and insurance companies into prescribing and paying for the newest medicines that are still under patent. When people start choosing 50¢ or 5¢ per pill alternatives, the pharma companies will lower their costs to compete. It may still be $5 or $15 per pill if they have a pill that is still covered by patent but competition with existing products will bring prices down, if only there is a little transparency and if we stop totally insulating customers from costs.

And I'm not exaggerating. There are pills out there where your doctor will prescribe you the newest $15,000 per month medicine and it will cost you a $10 co-pay. You could actually choose a generic where you would have to take two pills per day instead of one, but it is exactly the same medicine, and it would be $15/month. Why would a doctor prescribe the $15/month pill? there is a real benefit to having to take only one pill per day instead of remembering to take it twice. It's better for the patient to get the 1x/day pill. Why would the patient choose the cheaper pill? It costs the same to the patient.

And that is the tip of the iceberg when it comes to the kinds of shenanigans the pharma companies pull because of the lack of consumer transparency.

And you know what else? Insurance companies LOVE to pay more. Why? Because they pass the costs on in higher premiums but the fact that healthcare costs skyrocket means that people are terrified not to have complete head-to-toe coverage. So the more crap the pharma companies (and other providers) pull, the more the insurance companies laugh their way to the bank.

Quote from: dominicus on August 09, 2013, 01:05:24 AM

Quote from: smscotten on August 08, 2013, 11:06:00 AM

Carrying insurance, which insulates you from catastrophic or severe expenses is good. It is something everyone should have. Carrying a health plan that insulates you from every expense and makes every decision cost-neutral, on the other hand, is a terrible idea. It guarantees that you will pay more for your healthcare than you would have without it.

It may be a terrible idea to you, and I bet to many alert people with time to micromanage their healthcare, plan ahead, and have a stash of free cash for emergencies and "wellness" care. This is not the profile of the average US citizen, this is not even your 30th percentile citizen. I'm happy for you and you seem to have succeeded so far. However I disagree your stategy is widely applicable, or that it's a good idea to export it to those who are known to be ill-prepared to execute it.

Partial self-insurance is not a workable/sound idea for a population who, for various reasons, is unable to save even for their own retirement. 75% of US people nearing retirement have <$30K saved.

This just is not true. I live in one of the most expensive areas in the United States and these days my income is significantly below median. I have zero savings. I probably will not have a real meal today because I don't have the money for it. I am as close to bankrupt as you can possibly be; I could probably file for bankruptcy today and have no questions asked. If I had a sudden accident that led to a $10,000 medical bill, I could set up a payment plan with the hospital and not even get a nasty letter or a ding on my credit record. I have done this, and paid my bills. It's not easy or fun but it is possible. A low-deductable plan, on the other hand, brings crippling monthly insurance costs. I would soon be homeless if I were paying for a plan with a $250 deductable and all my office visits and medicines were covered.

It doesn't take a lot of time and effort to "micromanage" your healthcare and it doesn't take a huge stash of cash. All it takes is putting the same attention into buying healthcare services and insurance that you put into buying groceries. Actually, a whole lot less attention.

Quote from: dominicus on August 09, 2013, 01:05:24 AM

Quote from: smscotten on August 08, 2013, 04:27:41 AM

if you start talking about cost-effective medicine people freak out like it means cutting corners and getting shoddy care. But because I pay out of pocket, I get to make reasoned choices about the health care options in front of me...

Again, you may be good at negotiating, and it may provide you with instant savings. The skill and inclination to execute this isn't common, and it's not a strategy that will succeed for your average (especially below-average) population. There is an enormous, built-in imbalance of power in healthcare, and the patient is ALWAYS in the weakest (pun intended) position to negotiate. Why hang your hat in the weakest of all pegs?

I don't negotiate. I have never negotiated with my doctor. I pay my doctor my doctor's regular office visit fee. I ask what the cost is for a proposed treatment, I look up prices. I ask about alternatives. Again, this is not some special skill. It's called having a conversation with my doctor. My doctor says I'm one of his only patients that does that and he says he finds it refreshing. But it is not some magical medicine-negotiation-fu. It's just having a conversation, asking questions, and having my doctor make rational recommendations.

The closest I have come to a negotiation is when the NP wrote a new refill for 30mg tablets. I looked up the price and saw that the 30mg tablets were 90/month. If I chose to take three 10mg tablets per day instead it was $9. So I emailed asking whether she would write a new prescription for the 10mg tablets 3x/day. That was ten whole minutes out of my life.

Quote from: dominicus on August 09, 2013, 01:05:24 AM

"...get to make reasoned choices about the health care options in front of me"....really now? This must be close to verbatim what I read on a notice years ago...Human Resources smooth talk for higher premiums, higher co-pays, and higher out-of-pocket limits. But hey, they're doing us all a favor, we should all feel good 'cause now we're all empowered and motivated, and have skin-in-the-game, and I guess the HR people can sleep at night. I'll tell you, a decreasing amount of people actually find these statements convincing. Not because they're not achievable by some (i.e. there's a bit of truth in every good lie), but because by now everyone is aware they're impractical for most.

You're absolutely right to be suspicious of your HR department telling you that, but I think that with a tiny amount of research you'll find that even if what your HR person suggested was a boondoggle that the general principle will save you money.

Quote from: dominicus on August 09, 2013, 01:05:24 AM

You talk about regular checkups. The costs to deliver these are tiny compared to non-preventive care. Yet, a surprisingly large proportion of patients don't take advantage of annual wellness checkups even when included in their "subscription plan". I assert that the rate of preventive care will always be hopelessly worse with self-payers. Given the documented cost-benefit of catching conditions early, again another area your suggestions, as successful as they may prove to you, just don't scale and don't improve the overall system.

This suggests what I have been saying: people need to pay more attention and make better choices.

Quote from: dominicus on August 09, 2013, 01:05:24 AM

Quote from: smscotten on August 08, 2013, 04:27:41 AM

Unless people start paying for their own health care, this cycle will never end and eventually the country will be basically a "company town" where we all work for the health care industry.

Really? The cycle will *never* end? Well, signs already point to this not being the case, but no one can rule out we'll go a few more years of escalating HC costs.
That being said, you paint an impossible unraveling. We will NEVER become a "company town" where we all work to pay for HC. The people will install some form of "single-payer" long before we're anywhere near your prediction. Not a chance.

My prediction is that we'll be taking another run at a public option again in ~10 years time. No "company town".

OK. I don't refute your prediction. But I'm troubled by the fact that the "solution" to the healthcare crisis is to intentionally make things so much worse that people become desperate enough to have single payer when there are solutions in front of us that could knock the pharma and insurance companies on their asses and bring health care costs back into reason.

Look at the portion of our economy that goes to the healthcare industry, compare that to what it was twenty or fifty years ago, and then tell me that my "company town" prediction isn't close to the target, if admittedly overly dramatic. And if you think that we're going to go single payer without setting it up in such a way that that proportion doesn't increase and go directly into the pockets of the people who currently run big pharma and insurance, you have more faith in the charitable nature of Congress than I do.